Patient Factors for Treatment of Atopic Dermatitis

Lawrence F. Eichenfield, MD: Jeff, why don’t you start off here, because you’re the 1 who has the patient first. What patient factors do you consider when prescribing your treatment options?

Jeffrey M. Bienstock, MD, FAAP: I’ll take it 1 step back. Lisa just hit on this. Education and time are very important. Before I can go through any treatment modality with the family, whether it’s moisturizing their skin, topical steroids, using nonsteroidal medications, and then seeing a subspecialist who will give things I’m not comfortable with, it’s important to explain the need and how and why. Cost plays a role in this along with availability. Different ethnic groups will have different expectations on their skin. It’s important to have parents helping their children understand that you have to put this on twice a day and that if we keep your skin moist, you’re not scratching, and your nails are short, it can make a difference. We’ve gone through baths. What we’ve seen in the last 12 years has been a complete turnaround from where we were 12 years ago.

Expectations have to be there as we move through any kind of prescribing. Knowing what’s on their formulary is important. I could say, “I want this.” It’s “dispense as written” or it’s “substitute”—I still get calls from pharmacies saying, “We can’t fill that.” Well, I said replace it, basically. If you can’t do it, I’ll take care of it. Then there’s some anxiety with the family. “That’s not what you told me to use; I’m getting something different.”

It’s a lot of expectations and education as far as all the treatment. There are a lot of options. Some of the drugs that we talked about—the new nonsteroidals were a big game changer and a divergence from the typical medications. For primary care, knowing what falls into each category of potency is important. 

Lawrence F. Eichenfield, MD: We will be talking about dupilumab, our first biologic agent, and all the different systemic approaches. It’s not especially immunosuppressant. They’re allowed to say it’s not immunosuppressive, and it’s sort of a game changer. We’ll come back to that.

I just wanted to mention that in regard to factors for prescribing treatment options, traditionally, we’ll say it’s what they’ve used before, but it’s very important to assess how much they’ve used over a period of time. I work in a teaching situation. Many times the person who’s done the first evaluation comes in, and they say they’ve been using so and so. I ask, “How much?” They don’t know. I’ll say, “Let’s go in and see, because it could be that ‘15-gram tube for 4 months’ phenomenon,” which it often is. They’re using it twice a day and they’ve had a 15-gram tube for 4 months, so you realize it’s 1.5 grams a week. The politically incorrect analogy is, “I drink every day and a bottle of wine lasts 9 months.” The wine will go bad, but I’m not worried about the negative effect of alcohol on the system. It’s both what they’ve used—what they’ve used recently—and then the quantity that is very important to get a sense of whether they’ve been well controlled from a topical standpoint.

Transcript Edited for Clarity